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-8 - <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) in existence at the time <br />this application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34-32.5-115(4)(e), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34-32.5-115(4)(f), C.R.S.; <br />3. As the applicant/operator, I do not have any extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34-32.5-120, C.R.S.) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.R.S. <br />This forst has been approved by the !dined Land Reclamation Board pursuant to section 34-32.5-112,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for c pt rating <br />will:out a permit pursuant to section 34-32.5-123, C.R.S. <br />d <br />Signed and dated this 3 day of Gc 44 u ' Y , 2 C 1 <br />�.d(d'rf" L-0,4sretect:ael .y NG. <br />Applicant/Operator or Company Name <br />If Corporation Attest (Seal) <br />Signed: y� t;(. 7�� Signed: a. <br />Title: 5'CCtGl any 7't1a-74''c' <br />State of ,n d 6 -.. <br />County of f"r� ! n <br />) ss. <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoinA inistruipent was ac owledged before me this r3 r / <br />day of -Fe .n rk140-YY <br />10;5. , by > a as S'c.c , Tit A_S v —r of <br />MICHAEL S HOLLIS <br />NOTARYALLEN COuwBoma <br />ry <br />Comm. - Nov 18, <br />/ -// <br />6 titiwr-/ <br />Notary Public <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a <br />